Reflecting on ACP’s Position Paper for Public Health: A View From the CDC Lens
Authors: Sherri A. Berger, Rochelle P. Walensky
Journal: Annals of Internal Medicine (2023)

Editorials18 July 2023Reflecting on ACP’s Position Paper for Public Health: A View From the CDC LensFREESherri A. Berger, MSPH, Rochelle P. Walensky, MD, MPHSherri A. Berger, MSPHOffice of the Director, Centers for Disease Control and Prevention, Atlanta, GeorgiaSearch for more papers by this author, Rochelle P. Walensky, MD, MPHOffice of the Director, Centers for Disease Control and Prevention, Atlanta, GeorgiaSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M23-1455 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail For decades, the tireless dedication of our public health agencies has saved countless lives by mitigating the spread of disease. The Centers for Disease Control and Prevention (CDC) response to COVID-19, though, highlighted both organizational and operational challenges. Informed by feedback from hundreds of internal and external interviews, CDC announced an agency-wide effort—Moving Forward—to share science faster, to translate science into practical policy, to strengthen partnerships, to communicate better, and to be a more effective public health response agency (1). As CDC’s transformation began, numerous esteemed groups similarly opined on pandemic lessons learned; the position paper from the American College of Physicians (ACP) in this issue of Annals of Internal Medicine speaks to the future of public health from the physician perspective (2), complementing other reviews. Herein, we specifically highlight budget, workforce, and data.BudgetHealth security requires a strong public health system, and decades of underinvestment denied our country the reach necessary to tackle COVID-19. Supplemental funding remains critical to respond to and recover from public health crises. The temporary, inflexible, and threat-specific nature of supplemental funding—however large—leaves public health without permanent foundational capacity to develop sustainable robust infrastructures. Over one quarter of local health department funds emanate from direct or indirect federal sources (3), and over half of the domestic dollars CDC receives are distributed directly to jurisdictional health departments. As such, how funds are appropriated to CDC has an unambiguous impact on public health resources across the country. With its funds parsed into over 150 disease-specific budget lines and numerous Treasury accounts, CDC lacks flexible resources to address emerging threats or invest sufficiently in cross-cutting workforce, laboratory, readiness, and data capabilities. Even after an influx of pandemic funds, public health remains significantly underfunded. To optimally protect our nation, CDC needs increased funding, streamlining to a single Treasury account, and enhanced flexibility to allow a director to shift funding to strengthen an outbreak response (Table, top).Table. Authorities and Flexibilities That Would Benefit Public Health Response and ReadinessProposalDescriptionBudget flexibilities Enhanced budgetary authorityTo be a response-ready agency, CDC seeks authority to, when necessary, transfer a small proportion of funds from existing budget accounts to provide the CDC director with modest flexibility to rapidly address new or urgent problems before they escalate. One budget accountSupporting one budget account at CDC will enable the agency to better direct its key resources—its people—to address a public health crisis.Workforce authorities Noncompetitive fellowship conversion and noncompetitive term conversionAuthority to noncompetitively convert participants in fellowship/training programs, or term employees, to permanent positions would more effectively enable CDC to retain experienced employees of diverse backgrounds to meet workforce needs. Danger payCDC staff regularly deploy to work in dangerous situations. Allowing this authority to apply to those working in dangerous conditions with contagious and deadly diseases (e.g., Ebola) would help CDC recruit and retain staff. Overtime payEmployees are limited in the amount of overtime pay they can receive due to a pay cap. An exception to this cap for employees who work excess hours during an emergency response would provide equitable treatment to staff deployed on responses. Hiring authority exemption and ability to pay above caps for hard-to-fill positionsThe general schedule compensation has not attracted candidates to be on the forefront of informational data analysis for public health action. This authority would provide CDC the ability to directly hire and offer competitive wages for highly specialized positions that possess unique skills (e.g., data scientists). Student loan repayment tax waiverStudent loan debt and the need for more competitive salary was noted as the primary challenge to physicians applying to CDC fellowships. A tax exclusion would allow CDC to use additional resources to meet workforce recruitment needs and better compete with private sector salaries. Direct hire authorityResponding to emerging public health threats requires rapid surge staffing. Robust direct hire to surge staff during a PHE or significant likelihood of a PHE supports a faster and more effective response. Public health ready responseCDC has faced challenges maintaining sufficient staffing levels for the duration of a response. This authority provides CDC the ability to efficiently and effectively staff an emergency response. Reemployed annuitant maximum hours/dual compensation waiversAllowing reemployed annuitants to serve in a full-time capacity will ensure that experts who are willing to staff an emergency response are legally able to do so without penalty. Grants for governmental public health agenciesEffective public health response depends on action at the federal, state, and local levels of government. Explicit authority to direct funding to governmental agencies is needed to improve the timeliness of awards intended solely for state and local government recipients.Data authorities Public health data reportingThe current framework for collecting and sharing public health data has resulted in fragmented and inconsistent reporting to CDC, and to state and local public health partners. Modernizing the data policy framework will allow for more complete and timely data sharing to support decisions at the federal, state, and local levels, while reducing burden on providers. For example, authority included in the CARES Act required COVID-19 laboratory test reporting during the PHE greatly improved the availability of laboratory data but expired at the end of the PHE.CDC = Centers for Disease Control and Prevention; PHE = public health emergency. Download table Table. Authorities and Flexibilities That Would Benefit Public Health Response and ReadinessWorkforceHighlighted in ACP’s recommendations, but dire enough to merit repeating, the country needs an estimated 80% expansion in public health workforce capacity—an increase of 80 000 full-time personnel—to meet basic and expected public health standards (4). While the pandemic mobilized interest in public health careers, with, for example, a 20% to 25% growth in applicants to masters programs (Rasouli B. Personal communication.), this increase falls far short of the urgent need (5). Thus, we echo the import of creative strategies to foster and retain public health workers, including loan repayment and competitive pay benefits, additional pay for CDC and other public health staff engaged in intimate work with contagious and deadly diseases, incentives to work in underserved communities—in both rural and urban areas—and promotion of training in novel public health competencies (such as data science). Finally, CDC merits streamlined procedures to retain experienced and diverse CDC fellowship graduates, such as from the elite Epidemic Intelligence Service training program, to meet workforce needs (Table, middle).DataManual data entry, fax transmittal, nonstandardized data capture, and reliance on validated public health reporting hampered CDC’s ability to provide data for expeditious decision making early in the pandemic. Subsequently, supplemental funding and federal and jurisdictional data reporting requirements catapulted data modernization efforts across the public health spectrum. Innovations included the expansion of electronic case reporting from 187 health facilities in 2019 to more than 26 000 from 50 states today, with continued enrollment after the end of the public health emergency (6). Leveraging access to daily COVID-19–associated hospitalization data from hospitals supported by the Centers for Medicare & Medicaid Services, CDC provided county-level COVID-19 data for real-time decision making. As this was routinized, the public came to expect CDC’s timely, actionable, and digestible data for COVID-19; this sophisticated infrastructure was repurposed for mpox, where 43 states implemented electronic case reporting.Two important lines of work are necessary to improve on our current, still insufficient, state of health data in this country. First, we must securely link local and state public health data, so that we can then connect to similar interoperable and privacy-protected health care data highways across the United States (7). While Congress has provided CDC just over $1 billion since 2020 toward this effort, it is just a small fraction of what is needed for construction of a nationwide public health data infrastructure over the next decade. Although measured in billions of dollars, this investment in national data modernization must be viewed in the context of other large health care technology changeovers. For example, a single health system can spend over $1 billion to convert to electronic health record systems. Once these data highways are constructed, the second line of work requires secure access to public health data—that is, putting cars on the highways—and new authority to fix the patchwork system of incomplete, inconsistent, and slow voluntary data reporting (Table, bottom). Current laws speak to CDC’s responsibility for surveillance yet do not provide the legal framework to access the data necessary to deliver (8, 9).ConclusionsAlthough we have chosen to emphasize selected items in the ACP report, we also acknowledge the importance of other components. Strong coordination across the Department of Health and Human Services, for example, is critical. During outbreaks (such as mpox), focused Departmental leadership can coordinate laboratory assay development, validation and authorization, and deployment and reimbursement across agencies and with commercial markets. In addition, broiling mis- and disinformation have undermined efforts throughout the pandemic, from prevention and treatment to testing and vaccination. While we underscore the findings of the ACP report, combating insidious and nefarious actors will require mobilization from health care allies, in lockstep with federal, state, and local governments; nongovernmental organizations; the private sector; and the public.ACP’s position paper on public health infrastructure modernization joins a chorus of experts from across the nation demanding substantive change. We generally laud the findings: CDC, and our state and local public health partners, are heeding the call to take concrete action, and we report early successes. We also caution that we cannot act alone, and without funding, flexibility, and new authorities—in budget, workforce, and data—CDC and public health will be unable to respond to and avert the next pandemic. We must advance bipartisan solutions to fund, support, integrate, and empower public health.References1. Centers for Disease Control and Prevention. CDC Moving Forward. Updated 17 August 2022. Accessed at www.cdc.gov/about/organization/cdc-moving-forward.html on 23 May 2023. Google Scholar2. Crowley R, Mathew S, Hilden D; Health and Public Policy Committee of the American College of Physicians. Modernizing the United States' public health infrastructure: a position paper from the American College of Physicians. Ann Intern Med. 18 July 2023. [Epub ahead of print]. doi:10.7326/M23-0670 LinkGoogle Scholar3. National Association of County and City Health Officials. 2019 National Profile of Local Health Departments. 2020. Accessed at www.naccho.org/uploads/downloadable-resources/Programs/Public-Health-Infrastructure/NACCHO_2019_Profile_final.pdf on 23 May 2023. Google Scholar4. de Beaumont Foundation; Public Health National Center for Innovations. Staffing up: workforce levels needed to provide basic public health services for all Americans. October 2021. Accessed at https://debeaumont.org/wp-content/uploads/2021/10/Staffing-Up-FINAL.pdf on 23 May 2023. Google Scholar5. Leider JP, Plepys CM, Castrucci BC, et al. Trends in the conferral of graduate public health degrees: a triangulated approach. Public Health Rep. 2018;133:729-737. [PMID: 30227771] doi:10.1177/0033354918791542 CrossrefMedlineGoogle Scholar6. Centers for Disease Control and Prevention. Healthcare facilities in production for eCR. Updated 23 May 2023. Accessed at www.cdc.gov/ecr/facilities-map.html on 23 May 2023. Google Scholar7. U.S. Department of Health and Human Services. The Trusted Exchange Framework (TEF): principles for trusted exchange. January 2022. Accessed at www.healthit.gov/sites/default/files/page/2022-01/Trusted_Exchange_Framework_0122.pdf on 23 May 2023. Google Scholar8. Consolidated Appropriations Act of 2023, Pub. L. No. 117-328, §2211 (2022). Google Scholar9. Public Health Service Act of 2023, Pub. L. No. 117-356 (2023). Google Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Sherri A. Berger, MSPH; Rochelle P. Walensky, MD, MPHAffiliations: Office of the Director, Centers for Disease Control and Prevention, Atlanta, GeorgiaAcknowledgment: The authors thank Dr. Erika Wallender for her technical assistance and critical review of this manuscript.Disclosures: Authors have reported no disclosures of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-1455.Corresponding Author: Rochelle P. Walensky, MD, MPH, Centers for Disease Control and Prevention and Agency for Toxic Substances and Disease Registry, 1600 Clifton Road, Atlanta, GA 30329-4018; e-mail, [email protected]gov.This article was published at Annals.org on 18 July 2023. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoModernizing the United States’ Public Health Infrastructure: A Position Paper From the American College of Physicians Ryan Crowley , Suja Mathew , and David Hilden , for the Health and Public Policy Committee of the American College of Physicians* Metrics LatestKeywordsHealth promotionPrevention, policy, and public healthPublic policy ePublished: 18 July 2023 Copyright & PermissionsCopyright © 2023 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...